Making health financing work for the poor: An evaluation of equity in health systems financing in Indonesia

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Concerns about the poor and most vulnerable not getting adequate access to quality health care are widespread in low and middle income countries (LMICs) and have led to an intense advocacy for universal health coverage (UHC) in the last 5 years. Effective implementation of UHC requires equity in health care, defined as payment for health services according to capacity to pay and the receipt of benefits according to need. Indonesia has in recent years embarked on a programme to achieve UHC through a national health insurance scheme (Jaminan Kesehatan Nasional - JKN). However, with coverage currently at 65% and the 2019 goal for full coverage fast approaching, a second wave of JKN reforms are being planned to bolster Indonesia's progress.The primary aim of this study is to prospectively evaluate the combined effects of a second phase (2017-2019) of JKN-reforms in Indonesia and provide an overall assessment of progress toward the achievement to UHC. The reforms are designed to address factors currently hindering the effective implementation of the national health insurance scheme and in turn the pursuit of UHC by 2019. Over the next 3 years the government will be initiating and strengthening a number of important reforms ranging from re-structuring provider payment schemes through to socialization campaigns to raise awareness of the scheme and its benefits. Strategies for increasing fiscal space for health through increasing tobacco tax and the phasing out of subsidies on fuel are also proposed. Understanding the equity impact of these reforms and how they may (or may not) be facilitating progress towards UHC is of considerable interest to the government of Indonesia. The study will take a 'whole of system' approach by integrating both the public and the increasingly important private sector of the Indonesian health care system. Using a before and after design, the impact of these UHC reforms will be measured according to three key outcomes: (i) the progressivity of the health care financing system (ii) the pro-poorness of the health care delivery system and (iii) self-reported health outcomes across socioeconomic groups. The quantitative tools of financing and benefit incidence analysis will be used to assess who pays and who benefits from health care spending at baseline (2017) and 2 years into implementation (end 2019). The study will bring together an international research team consisting of those with substantial experience of evaluating UHC-reforms in Africa and the Asia-Pacific and those with an in-depth understanding of the Indonesian health care system. Qualitative studies to document the context pre and post UHC reforms, and the process of implementing UHC reforms will also be undertaken. Stakeholder analysis will be used to support the translation of priority financing reforms identified through the evaluation into viable policy proposals.The study will advance methods in this field by testing different indicators and indexes of 'need', against which the appropriateness of the distribution of benefits from using health services can be assessed. The study will also advance knowledge through a better understanding of the contribution of the private sector to meeting the needs of the poor and in turn, inform through the stakeholder analysis, ongoing discussions about effective engagement with private sector to strengthen progress towards UHC.The over-arching goal of this study is to strengthen the healthcare system of Indonesia through more equitable and sustainable health financing policies. As the fourth most highly populated country in the world, with a total population of around 255 million people, the implications of this study's findings for the design of a universal health system will be far-reaching.